Venous access for patients with chronic kidney disease.

ESTABLISHING and maintaining reliable intravenous access for patients with chronic renal failure or end-stage renal disease presents special considerations unique to this patient population. These patients often present with complicated medical conditions requiring intravenous medical therapies; at the same time, there is a critical need to preserve the peripheral and central veins for future hemodialysis access. The native arteriovenous fistula is the preferred form of vascular access for hemodialysis, delivering superior patency with lower morbidity, hospitalization, and cost relative to synthetic grafts or venous catheters (1). For these reasons, the nephrology community has implemented a nationwide agenda to increase the creation of native fistulas in our hemodialysis patients. The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) was published in 1997, with specific guidelines relative to creation and management of hemodialysis vascular access (2). More recently, the Centers for Medicare and Medicaid Services along with the regional ESRD Networks and the clinical nephrology community have developed and promoted the National Vascular Access Improvement Initiative (NVAII), with the specific goal of promoting more native arteriovenous fistulas in United States hemodialysis patients (3). Ultimately, however, our ability to create functional fistulas is critically dependent on the availability and condition of the patient’s peripheral veins. Frequent venipuncture and the indiscriminate use of peripherally inserted central catheters (PICCs) or central venous catheters can damage veins and jeopardize future fistula construction. Therefore, it is of paramount importance that patients who have or are at risk for renal failure are identified and their venous access be restricted to preserve peripheral veins for future vascular access construction. This important concept has been emphasized in editorials by Trerotola related to the publication of the original DOQI vascular access guidelines (4,5), and more recently in updated NKF-K/DOQI guidelines (6).